Corrective Action Plans

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Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization shou...
Condition –The Organization determines the sliding fee discount charged to the patients based on their annual gross income and household size. During our testing of sliding fee discounts, we found two encounters where the patients were charged incorrect copays. Recommendation – The Organization should strengthen processes surrounding the monitoring of the program to ensure the Organization’s policies are consistently and properly applied. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Organization has developed a plan for addressing this issue that includes updated procedures, training, and auditing. All teams engaged in the patient collection, enrollment, and eligibility process will be retrained on the process with emphasis on proper documentation and provide feedback and retraining as necessary to staff as needed. Anticipated Date of Completion – By October 31, 2025. Action Taken – Management has scheduled time at front desk/billing meetings to retrain staff on processes that ensure appropriate sliding fee rates are utilized for each sliding fee encounter. Specifically, training will focus on encounters with both an office visit and lab are properly identified so that the lab co-pay is adjusted appropriately. Person Responsible for Corrective Action Plan – Steven Leazer, Chief Financial Officer.
View Audit 366550 Questioned Costs: $1
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures...
2025-004 Cash Management (repeat of finding 2024-008) Corrective action planned: Beginning April 1, 2025, when the organization was made aware of this finding in last year’s audit, OMC took immediate corrective action. The CFO/Designee monitors expenses and prepares a detailed report of expenditures claimed for reimbursement and retains this documentation along with supporting invoices. A qualified, knowledgeable CFO will continue to ensure compliance with these requirements. Anticipated completion date: Corrective Action taken on April 1, 2025. Contact person responsible for corrective action: Allen Boyd, Director of Fiscal Operations
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fe...
Federal Program: Consolidated Health Centers Grant Assistance Listing No. 93.224 & 93.527 Recommendation: Our auditors recommended the Organization to review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review internal controls in regards to the determination, recording, and monitoring of the sliding fee process to ensure that appropriate sliding fee rates/categories are utilized for each sliding fee encounter. Management meetings will be scheduled with the COO, Director of Operations, and Dental Billing Supervisor(s) to provide updates on progress. Periodic internal auditing of sliding fee scale dental files will be completed. Quarterly management review of sliding fee scale program progress until Athena Dental is fully integrated with Athena Medical, where electronic health record issues were not detected regarding sliding fee scale adjustments. If the U.S. Department of Health and Human Services has questions regarding this plan, please call Kevin Maddox, CFO, at 636-236-5180
The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that it has been determined that where incorrect drawdowns were made - they were underdrawn, not overdrawn. No drawdowns were determined to include anything beyond known, justifiable, a...
The Agency acknowledges this error and agrees with the recommendations. The Agency provides the additional context that it has been determined that where incorrect drawdowns were made - they were underdrawn, not overdrawn. No drawdowns were determined to include anything beyond known, justifiable, and allowable expenses. Previous T &TA support from the Office of Head Start and monitoring reviews from other fiscal agencies had not previously revealed this concern and recommendations were made to carry out drawdowns in this manner. The Finance department is actively working with the new recommendation from the auditors to use the accounting system (MIP) and to implement a new payroll and reconciliation procedure which will prevent future errors.
Finding 576088 (2025-003)
Significant Deficiency 2025
Finding 2025-003: Account Reconciliation Procedures Type of Finding: Control U.S Department of Housing and Urban Development Direct program Assistance Listing Number: 14.251 Award Numbers: B-24-CP-MI-1149 Award Year End: August 31, 2032 Recommendation: The Township should establish proced...
Finding 2025-003: Account Reconciliation Procedures Type of Finding: Control U.S Department of Housing and Urban Development Direct program Assistance Listing Number: 14.251 Award Numbers: B-24-CP-MI-1149 Award Year End: August 31, 2032 Recommendation: The Township should establish procedures to verify that expenditures are properly tracked by individual grant to ensure that individual disbursements are not allocated to more than one grant. Action Taken: The Township will create a spreadsheet to track expenditures by individual grants that will be updated as individual disbursements and receipts occur. Responsible Person and Anticipated Completion Date: Township Treasurer, March 31, 2026. If the Michigan Strategic Fund has questions regarding this plan, please call Rebecca Griffin at 231-861-5853.
Finding 2025-001 Corrective Action Plan. Management has re-reviewed the policy and requirements for failed HQS inspections with staff and contracted inspectors to ensure understanding and reinforce the timelines and actions required to address deficiency corrections, follow-up inspections and enforc...
Finding 2025-001 Corrective Action Plan. Management has re-reviewed the policy and requirements for failed HQS inspections with staff and contracted inspectors to ensure understanding and reinforce the timelines and actions required to address deficiency corrections, follow-up inspections and enforcement, including rent abatement. Further internal procedures implemented to ensure additional contractor oversight and postrepair audits to ensure that failed HQS inspections are remedied properly and timely. Responsible Party: Andrea Fink, Housing Programs & Services Manager Timeline: Full implementation of the CAP by 9/15/2025 This Corrective Action Plan has been reviewed and approved by: -;t((t ih= Rob L. Fredericks (Aug 20. 2025 10:00:43 PDT) Rob L. Fredericks Executive Director/CEO
Statement of condition #2025-001 Comments on the finding and each recommendation: The Partnership received a score of 57 in a physical inspection of the Property performed on March 19, 2024 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. As of ...
Statement of condition #2025-001 Comments on the finding and each recommendation: The Partnership received a score of 57 in a physical inspection of the Property performed on March 19, 2024 by a representative of HUD. By reference, the REAC inspection is included as a statement of condition. As of March 31, 2025, the physical inspection is closed. Action(s) taken or planned on the finding: Management has responded to HUD in regard to this inspection report and has addressed all exigent health and safety issues.
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP ...
Corrective Action Plan Year Ended April 30, 2025 To Health Resources and Services Administration United Methodist Western Kansas Mexican-American Ministries, Inc. d/b/a Genesis Family Health respectfully submits the following corrective action plan for the year ended April 30, 2025. CohnReznick LLP 350 Church Street Hartford, CT 06103 Audit Period: April 30, 2025 The findings from the April 30, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. Financial Statement Findings: Finding 2025.001 - Sliding Fee Scale Documentation Recommendation The Organization should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken GFH implemented an O&E Department (Onboarding and Enrollment) July 2023. This has been a timely process, but it has been implemented across all clinic sites. The purpose of this department is to ensure all required documentation is current, accurate, scanned in chart and applied to patients EMR. This process includes current registration, slide application, POIs, IDs and insurance verification for coverage. All patients are required to complete an onboarding and enrollment appointment to ensure required information is added to the patient’s account and the sliding fee discount is accurately applied. The slide application with the incorrect discount was completed on 06/27/2023 and the patient returned to the clinic for a follow-up appointment on 6/17/2024 (10 days prior to the annual O&E update appointment). All other accounts audited were after the O&E implementation in July 2023 and no errors or deficiencies were identified. Additionally, Genesis Family Health has implemented a mandatory annual review process for all staff with electronic acknowledgement of the staff member's understanding of the Sliding Fee Discount Policy. If there are any questions regarding this plan, please contact Amanda Vaughan at: Amanda.Vaughan@genesisfh.org Sincerely, Amanda Vaughan (electronically signed 7/31/2025) Amanda Vaughan - Chief Financial Officer
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residua...
Statement of Condition 2025-001 (Assistance Listing 14.155): The Corporation did not make the required residual receipts deposit computed at April 30, 2024 in the amount of $69,120 within 90 days of fiscal year end. Recommendation: Management should implement a system to ensure the required residual receipts deposit is made within 90 days of fiscal year end. Management response: Agree. Management made the required residual receipts deposit on January 8, 2025.
View Audit 365221 Questioned Costs: $1
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, an...
Managements Corrective Action Plan For the year ended March 31, 2025 Finding 2025-001- lnterprogram Due To/ Due From Activities Views of responsible officials and planned corrective action: Beeville, TX 78102 The Housing Authority will implement monthly transfers of all due to/ due from balances, and if there is a balance that cannot be repaid, a payment plan will be established. Working with fee accountants during this process monthly will ensure there are no balances remaining at year end.
Finding 572429 (2025-001)
Significant Deficiency 2025
Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non...
Finding 2025-001 Personnel Responsible for Corrective Action: Deborah Vinnola, Registrar Anticipated Completion Date: September 30, 2025 Corrective Action Plan: The Office of the Registrar has put into place a more detailed corrective action plan regarding the finding of delayed enrollment and non-enrollment reporting to NSLDS through NSC. The Office of the Registrar has adjusted the Degree Verify submission from every 45 days to every 30 days to NSC to ensure graduation dates are reported in a more timely fashion for NSLDS within the required 60 days for financial aid. Starting Summer 2025, the Office of the Registrar has begun inactivating academic programs for students who have not had registration activity within the last two to three academic years to ensure that they are not reported as enrolled to NSC/NSLDS. NSC Enrollment Reporting will continue to be submitted every 30 days and the Office of the Registrar has worked to review the reporting criteria using terms and not semesters to better report active enrollment in current courses. The Ellucian Graduation Application form and process is in the final stages of testing which will eliminate completely the need to add a pseudo course with a future date after the student’s current program has been inactivated or graduated. The Office of the Registrar will be more proactive with the colleges for identifying students who have not graduated within the six year (undergraduate), four year (graduate) and certificate time frames by working with the appropriate dean’s offices. This should eliminate those students who have completed their coursework; close to completing their coursework but were never reviewed by their advisor/program for graduation. Since Regis uses the end date of the last course completed, the Office of the Registrar will work with advising units to review the lists to increase a better reporting of degree completion.
Statement of condition 2025-001: During the year ended March 31, 2025, management submitted a 9250 to withdraw funds from the reserve for replacements fund that included the same invoice as a previously approved 9250. The reserve for replacements account was not reimbursed for the duplicate withdraw...
Statement of condition 2025-001: During the year ended March 31, 2025, management submitted a 9250 to withdraw funds from the reserve for replacements fund that included the same invoice as a previously approved 9250. The reserve for replacements account was not reimbursed for the duplicate withdrawal. Comments on the finding and each recommendation: Management should transfer $14,376 from the operating cash account to the reserve for replacements account. Action(s) taken or planned on the finding: Management concurs with the finding and recommendation. On May 29, 2025, management transferred $14,376 from the operating cash account to the reserve for replacements account.
View Audit 362933 Questioned Costs: $1
Statement of Condition 2025-001 (Assistance Listing 14.157): The Property received a score of 49 on a physical inspection of the Property performed on June 17, 2024 by a representative of HUD. By reference, the NSPIRE inspection is included as a statement of condition. Recommendation: Management ...
Statement of Condition 2025-001 (Assistance Listing 14.157): The Property received a score of 49 on a physical inspection of the Property performed on June 17, 2024 by a representative of HUD. By reference, the NSPIRE inspection is included as a statement of condition. Recommendation: Management should ensure all necessary repairs have been made. Management should continue to conduct routine unit and general property inspections and deficiencies should be corrected in a timely manner. Management Response: Agree. Management has responded to HUD regarding this inspection report and has addressed all health and safety issues. On May 16, 2025, a new physical inspection was completed at the Property and received a passing score of 87.
1. Reimbursed the Replacement Reserve Account: The missed deposits totaling $663 were reimbursed to the replacement reserve on May 30, 2025. 2. Implemented Monthly Oversight Meetings: Beginning in January 2025, we instituted monthly meetings to review financial statements, budgets, forecasts, and...
1. Reimbursed the Replacement Reserve Account: The missed deposits totaling $663 were reimbursed to the replacement reserve on May 30, 2025. 2. Implemented Monthly Oversight Meetings: Beginning in January 2025, we instituted monthly meetings to review financial statements, budgets, forecasts, and compliance-related data. These meetings include key stakeholders and team members to ensure timely discussions of financial status, variances, and compliance matters. This structure enhances accountability and provides regular managerial oversight.
Comments on Finding and Recommendation: The Corporation paid management fees of $2,480 in excess of the amount approved by HUD. The HUD approved management agent certification (Form HUD-9839-B) provides for the payment of management fees equal to 5.93% of residential and miscellaneous income collec...
Comments on Finding and Recommendation: The Corporation paid management fees of $2,480 in excess of the amount approved by HUD. The HUD approved management agent certification (Form HUD-9839-B) provides for the payment of management fees equal to 5.93% of residential and miscellaneous income collected. Action(s) taken or planned on the finding: Management agrees with the recommendation. The Agent intends to reimburse the Corporation the overpayment of management fees.
View Audit 361607 Questioned Costs: $1
Finding 570576 (2025-001)
Significant Deficiency 2025
Finding 2025-001: Comments on the Finding and Each Recommendation: During the year ended March 31, 2025, the Corporation withdrew $6,905 from the reserve for replacements without a HUD approved 9250.The Corporation should transfer $6,905 from operating cash into the reserve for replacements. Action...
Finding 2025-001: Comments on the Finding and Each Recommendation: During the year ended March 31, 2025, the Corporation withdrew $6,905 from the reserve for replacements without a HUD approved 9250.The Corporation should transfer $6,905 from operating cash into the reserve for replacements. Action(s) taken or planned on the finding Management concurs with the recommendation. On April 26, 2024, the Corporation transferred $6,905 from the operating cash account to the reserve for replacement account.
View Audit 361606 Questioned Costs: $1
Statement of Condition 2025-002 (Assistance Listing 14.157): During the year ended January 31, 2025, 1 move-out resident file selected for testing under the compliance supplement were missing necessary documents required by the PRAC and HUD Handbook 4350.3. Recommendation: Management should ensure ...
Statement of Condition 2025-002 (Assistance Listing 14.157): During the year ended January 31, 2025, 1 move-out resident file selected for testing under the compliance supplement were missing necessary documents required by the PRAC and HUD Handbook 4350.3. Recommendation: Management should ensure that all resident files are maintained at the site for each resident of the Property in accordance with the HUD Handbook 4350.3. Management Response: Management agrees with the recommendation and will ensure that resident files are retained in accordance with the HUD Handbook 4350.3. The resident moved-out on June 13, 2024. No further action is required.
Statement of Condition 2025-001 (Assistance Listing 14.157): During the year ended January 31, 2025, HUD approved $83,950 of withdrawals as a pre-release to pay for HVAC replacements and boilers at the Property. The Corporation used $24,300 of the pre-release to fund operations, instead of paying th...
Statement of Condition 2025-001 (Assistance Listing 14.157): During the year ended January 31, 2025, HUD approved $83,950 of withdrawals as a pre-release to pay for HVAC replacements and boilers at the Property. The Corporation used $24,300 of the pre-release to fund operations, instead of paying the invoices approved by HUD and had not paid as of January 31, 2025. Recommendation: Management should ensure that HUD approved reserve for replacement withdrawals are used for the approved purposes. Management Response: Agree. The Corporation paid the remaining costs included in the HUD approved withdrawal on March 3, 2025. There is no further action required.
View Audit 355850 Questioned Costs: $1
The College acknowledges the finding and is currently working toward resolving the identified deficiencies related to the GLBA Safeguards Rule. The College has designated a Qualified Individual (QI) to oversee compliance and is in the process of developing a formal written Information Security Progr...
The College acknowledges the finding and is currently working toward resolving the identified deficiencies related to the GLBA Safeguards Rule. The College has designated a Qualified Individual (QI) to oversee compliance and is in the process of developing a formal written Information Security Program (ISP), which will be integrated into its Information Technology Policy. The FAO Policies and Procedures Manual and other relevant internal policies will be aligned with, and reference, the GLBA requirements established in the College's Information Technology Policy to ensure consistency and compliance with federal requirements.
The College acknowledges the finding and is working with JFA Support to customize its financial aid award letters to meet federal Title IV notification requirements. In addition, the College is implementing FAFSA priority deadlines before each semester to allow sufficient time for staff to review st...
The College acknowledges the finding and is working with JFA Support to customize its financial aid award letters to meet federal Title IV notification requirements. In addition, the College is implementing FAFSA priority deadlines before each semester to allow sufficient time for staff to review student eligibility, complete packaging, and process awards accurately. With the implementation of JFA's automated packaging and disbursement features, the College aims to improve award accuracy, reduce manual errors, and strengthen monitoring of student credit balances to ensure timely disbursements in compliance with federal requirements.
The College acknowledges the finding and recognizes the need to strengthen coordination, reconciliation, and documentation procedures to ensure accurate and timely reporting of expenditures under the Form SG2 Performance and Financial Evaluation reports. The College recognizes that the lack of regul...
The College acknowledges the finding and recognizes the need to strengthen coordination, reconciliation, and documentation procedures to ensure accurate and timely reporting of expenditures under the Form SG2 Performance and Financial Evaluation reports. The College recognizes that the lack of regular follow-up and reconciliation between CMI and the Ministry of Finance (MOF) contributed to discrepancies in reported expenditures. During FY2025–FY2026, the College has been working closely with MOF to review and reconcile reported expenditures, provide supporting documentation, and address identified discrepancies. The College continues to strengthen coordination with MOF to ensure that expenditures reported in the SG2 are properly supported, reviewed, and agreed upon by both parties. Additionally, the College is improving its internal review and documentation procedures to ensure that financial reports are accurate, complete, and consistent with underlying accounting records. These ongoing collaborative efforts are intended to improve communication, strengthen accountability, and establish a more effective reconciliation and follow-up process between CMI and MOF to prevent similar reporting discrepancies in future audits.
The College acknowledges the repeated finding and recognizes the need to strengthen internal controls to ensure that expenditures charged to federal programs are incurred within the approved period of performance. During FY2025–FY2026, the College continued implementing corrective measures, includin...
The College acknowledges the repeated finding and recognizes the need to strengthen internal controls to ensure that expenditures charged to federal programs are incurred within the approved period of performance. During FY2025–FY2026, the College continued implementing corrective measures, including the use of an upgraded cloud-based filing system to improve documentation, monitoring, and verification of grant funding periods. The College has also continued strengthening coordination among the Business Office, Human Resources, and program personnel to ensure that payroll expenditures are properly reviewed and aligned with the applicable grant award periods. Additionally, the College continues to improve its review procedures to ensure that payroll costs are charged based on the actual period in which services were performed rather than the payment date. The College will also review the identified questioned costs and determine whether any adjustments or additional corrective actions are necessary. These ongoing efforts are intended to strengthen compliance with federal period of performance requirements and prevent recurrence of similar findings in future audits.
The College acknowledges the finding and recognizes the need to strengthen internal controls over equipment and real property management to ensure compliance with applicable federal requirements. During FY2025–FY2026, the College continued its efforts to improve the accuracy, completeness, and maint...
The College acknowledges the finding and recognizes the need to strengthen internal controls over equipment and real property management to ensure compliance with applicable federal requirements. During FY2025–FY2026, the College continued its efforts to improve the accuracy, completeness, and maintenance of its capital asset records. These efforts include working toward the implementation of the MIP Fixed Asset Module to improve asset tracking, documentation, and reconciliation of fixed asset records with the general ledger. The College is also working to strengthen procedures for maintaining complete asset information, reconciling physical inventory results with equipment records, and ensuring proper safeguarding and monitoring of College assets. Additionally, the College will improve its procedures for reviewing asset conditions, identifying potential impairment, and maintaining appropriate documentation for asset disposals. These ongoing corrective measures are intended to strengthen accountability, improve the reliability of capital asset records, and prevent recurrence of the finding.
U.S. Department of Treasury COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that management review their policies and procedures to ensure that all monthly and quarterly reports are submitted timely, and the supporting docu...
U.S. Department of Treasury COVID-19 - Coronavirus State and Local Fiscal Recovery Funds - Assistance Listing Number 21.027 Recommendation: We recommend that management review their policies and procedures to ensure that all monthly and quarterly reports are submitted timely, and the supporting documentation used to prepare the reports retained for audit purposes. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review and update existing policies and procedures for the SLFRF program to establish formal requirements for preparing, reviewing, approving, and submitting all applicable monthly and quarterly reports by their respective deadlines. Management will develop a reporting calendar identifying all required reports and submission deadlines. Management will Conduct periodic monitoring to verify that reports are submitted timely, supporting documentation is retained, and any identified reporting deficiencies are corrected promptly. Name(s) of the contact person(s) responsible for corrective action: Township Manager and Finance Officer Planned completion date for corrective action plan: Initial procedures and checklists will be developed within 60 days. The revised controls will be fully applied during the next year-end close, subject to the applicable fiscal year-end schedule.
The Clerk has. on occasion. had issues accessing the system on the last day due to heavy traffic, causing reports to be submified late. Going forward, reports will be accurately compiled and submitted at least l0 days prior to the report due date to avoid issues with connectivity.
The Clerk has. on occasion. had issues accessing the system on the last day due to heavy traffic, causing reports to be submified late. Going forward, reports will be accurately compiled and submitted at least l0 days prior to the report due date to avoid issues with connectivity.
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